What are the complications of frequent suctioning?

Complications of Frequent Suctioning

Frequent airway suctioning causes significant mucosal trauma leading to tracheal and bronchial stenosis, granuloma formation, bleeding, and infection—complications that can be substantially reduced by limiting suctioning to only when clinically necessary and restricting catheter passage to the distal tip of the artificial airway.

Major Structural Complications

Tracheal and Bronchial Stenosis with Granuloma Formation

Repeated mucosal injury from suction catheters is the primary mechanism for developing tracheal and bronchial stenosis, particularly in the distal trachea and right-sided bronchi. 1

• Stenosis and granuloma formation occur in 1.2 to 36% of infants with chronic lung disease who undergo frequent suctioning 1
• Endoscopic findings reveal airway narrowing or occlusion by thickened respiratory mucosa with circumferential nodular or polypoid granulations in the distal trachea, often extending into main bronchi 1
• Histologically, these lesions show squamous metaplasia, ulceration of overlying epithelium, and fibrosis in the mucosa and submucosa 1
• Acute mucosal injury to the carina and main bronchi occurs from unrestricted or "deep" suctioning 1

Critical evidence: One nursery that changed from deep to shallow suctioning techniques demonstrated qualitatively less severe airway damage, even though the shallow-suctioned group was younger and received longer mechanical ventilation 1

Tracheobronchomalacia

• Central airway collapse has been documented in 45% with tracheomalacia and 34% with bronchomalacia among infants with chronic lung disease undergoing bronchoscopy 1
• This complication is attributed to barotrauma, chronic infection, and local effects of artificial airways including frequent suctioning 1

Hemorrhagic Complications

Bleeding from Suction Trauma

Bleeding from suctioning must be differentiated from sentinel bleeding that occurs from arterial erosion, which can be catastrophic. 1

• Hemorrhagic secretions occur in 31.6% of subjects and 4% of individual suctioning procedures 2
• Minor endotracheal bleeding is common during routine tracheal suctioning and results from tracheal epithelial abrasions 1
• The possibility of catastrophic bleeding from tracheal erosion into a major artery exists with tracheostomy 1
• Receiving more than 6 suctionings per day is an independent risk factor for hemorrhagic secretions 2

In COVID-19 patients on anticoagulation, bleeding risks are substantially amplified, with mortality risks approaching 10% 1

Respiratory Complications

Hypoxemia and Desaturation

• Oxygen desaturation occurs in 46.8% of subjects and 6.5% of individual suctioning procedures 2
• PEEP > 5 cm H₂O is an independent risk factor for oxygen desaturation during suctioning 2
• Atelectasis can result from excessive negative pressure during suctioning 3, 4

Tube Occlusion Risk

Paradoxically, reducing suctioning frequency to minimize trauma can increase risks of tube occlusion, particularly with thick secretions. 1

• Thick, tenacious secretions predispose to tracheostomy tube occlusions, a widely recognized cause of hypoxia and respiratory arrest 1
• This risk is increased by both mindful reduction in frequency of suctioning and general aversion to suctioning 1

Cardiovascular Complications

• Blood pressure changes occur in 24.1% of subjects and 1.6% of suctioning procedures 2
• Heart rate changes occur in 10.1% of subjects and 1.1% of suctioning procedures 2
• Cardiac dysrhythmias and, in extreme cases, cardiac arrest can occur 4, 5
• Elevated intracranial pressure may result from suctioning 3, 4

Infectious Complications

Recurrent infection (tracheitis and/or bronchitis) is a common complication of frequent suctioning. 1

• Tracheostomies rapidly become colonized, making cultures of tracheostomy secretions not always helpful 1
• Concomitant infection in the setting of mucosal injury has been proposed as a risk factor for subglottic stenosis 1

Evidence-Based Prevention Strategies

Suctioning Technique Modifications

The most important preventative measure is to restrict passage of the suction catheter to the distal tip of the artificial airway, protecting the airway mucosa from injury. 1

• Suction only when clinically necessary, not on a routine schedule 3, 2
• Use a suction catheter that occludes less than half the lumen of the endotracheal tube (usually 5-6F in newborns) 1, 3
• Use negative pressures no greater than 50-80 cm H₂O—higher pressures increase mucosal damage without improving secretion removal 1, 3
• Suction for no longer than 15 seconds 3
• Perform continuous rather than intermittent suctioning 3

Catheter Design Considerations

• Catheters with multiple side holes on several planes are less likely to cause invagination of airway mucosa than those with single side or end holes 1

Oxygenation Support

• Provide hyperoxygenation before and after the suction procedure 3, 4
• Provide hyperinflation combined with hyperoxygenation on a non-routine basis 3

Frequency Considerations

Receiving more than 6 suctionings per day is an independent risk factor for both desaturation and hemorrhagic secretions. 2

Overall Complication Rates

Implementation of evidence-based suctioning guidelines significantly reduces complications:

• Before guidelines: adverse effects occurred in 59.5% of subjects and 12.4% of procedures 2
• After guidelines implementation: complications decreased to 42.6% of subjects and 4.9% of procedures (both P < 0.05) 2

Critical Clinical Pitfall

The most common error is performing "deep" or unrestricted suctioning that extends beyond the artificial airway tip. This practice directly causes the distal tracheal and bronchial injuries that lead to stenosis and granuloma formation 1. When bleeding occurs from suctioning, flexible endoscopic evaluation through the tracheostomy tube allows assessment of trauma and appropriate counseling of caregivers 1.